(1) Write in strict accordance with relevant regulations (1) Write in blue-black ink or carbon ink; ② Use Chinese and medical terms, standardize and correctly write commonly used abbreviations in foreign languages, and use full names of medical terms, which cannot be simplified at will; (3) Arabic numerals should be used for numerals with quantifiers, and Chinese characters or the mixture of Chinese characters and Arabic numerals cannot be used; ④ Drugs can be written with chemical names or trade names, and cannot be replaced by chemical molecular formulas; (5) The recorder's name should be written in full name and position, so the patient's relatives should indicate the relationship with the patient. For example, the head nurse should write ×××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××
(2) Signing and signing (1) Signing points of nurses on duty: nurses on duty are responsible for all nursing work during the shift, carefully observe the patient's situation when taking over, and record the signature; During the shift change, every time 1 operation is made, or the patient's condition is observed according to the requirements of nursing level and the condition, it needs to be recorded and signed; Summarize and record the patient's condition before handover and sign it; Record and sign for 12 hours, and record and sign for 1 time every 24 hours; Seriously ill patients should write a summary and sign it, and patients should write a death summary and sign it after death. ② Signing points of nurses in internship or probation period: The nursing records and signatures written by nurses in internship or probation period are the same as those of nurses on duty, but they should be reviewed by the teaching nurses and signed by them. Specific writing: name of intern nurse/name of teaching nurse. ③ Key points for the head nurse to check and sign: The head nurse is responsible for the quality of general nursing work and nursing documents, and should check, guide and sign the nursing work and records of critically ill patients every day; Check and sign the medical records of seriously ill patients and dead patients.
⑶ Correction method of writing errors: When there are typos or clerical errors in the writing of nursing records, nurses should not cover up or remove the original handwriting by gluing, smearing and redrawing, but should draw double lines at the wrong place, write the correct words on the upper right, indicate the date of revision and sign. The nurse used a blue-black pen and the head nurse used a red pen to correct it. There are 2 modifications per page, and the page should be copied again if there are more than 3.
⑷ Time requirement for recording: The starting time of each record should include year, month, day, hour and minute; Continuously record the changes of illness and the time of treatment; The same time can be omitted from the 1 page document. For example, when patients were admitted to hospital in 2005, it was stated in the first record that there would be no record after this time limit, and 2005 could be omitted, and the writing requirements for the month and day were the same as those of that year.
5] Number of records: Nurses should pay attention to the writing of nursing records, form a good habit of recording in time after work, and avoid missing or making up records. Specific requirements: ① After the succession, the patient's condition should be recorded when inquiring and checking the patient; (2) Summarize the dynamic changes of patients' condition, main nursing measures, effects and problems needing special explanation and attention before the shift change; ③ Record the patient's chief complaint, discomfort, condition change, special examination, treatment and disposal, medication, pre-and post-operation situation and family conversation at any time; (4) Even when the critically ill patients' condition is relatively stable, they should be inspected every 15 ~ 30 minutes/time according to the first-class nursing standard; ⑤ In general, the nursing records of critically ill patients are recorded in real time. However, when the condition suddenly changes and the patient has an accident, the records affected by the rescue should be truthfully supplemented and marked within 6 hours after the rescue.
2. Content requirements of records
(1) The content is accurate: The nursing record should accurately record the patient's chief complaint, changes of illness and signs, and there should be no vague and ambiguous descriptions, such as hypotension, excessive bleeding and adjustment of dopamine drops. Blood pressure value, blood loss, intravenous infusion drops per minute, drug dosage and unit should be written in detail. For example, the description of the patient's consciousness should specifically include sobriety, vagueness, lethargy, shallow coma and deep coma.
⑵ Complete record: completeness means that everything recorded must have a cause, a process and a result. If the condition changes, it should reflect the cause, time, clinical manifestations, diagnosis and analysis, specific treatment and results of the condition; Staff should write down the specific time, location, name, content, etc. during rounds, rescues and operations. And there is a beginning and an end, and there is a cause and a result. If the patient complains of headache, then the perfect observation, inquiry, examination and treatment should be written as follows: The patient begins to feel persistent tightness in the top of his head in the morning, measure his blood pressure 160/ 100mmHg, report to the doctor and take nifedipine 10mg sublingually, and continue to observe the blood pressure changes. Description: 10:00 The patient's heartbeat and breathing stopped suddenly when he went to the toilet with the help of his family. 10:0 1 The nurse on duty rushed to the ward to check that the patient's heartbeat and breathing had stopped, and urgently called the doctor to the scene for rescue. At the same time, he immediately gave the patient oxygen and continued chest compressions. But the nursing record says "the patient is weak, breathing slowly, blood pressure drops, etc." Failure to explain clearly the actual situation that the patient's condition changes when he gets out of bed and goes to the toilet may affect the doctor's judgment and treatment of the condition changes.
⑶ Objective truth: Nursing records should objectively record what nurses observed, including what they heard, saw and smelled, and should not be mixed with nurses' subjective imagination. For example, according to nursing records, the patient underwent right lobe hepatectomy, and the operation was smooth and the condition was stable. Return to the ward safely at 13:00. The description of "smooth operation and stable condition" is not objective data, because the nurses in the ward did not participate in the operation process and did not see the situation during the operation. Postoperative nursing records of patients should mainly describe the name of operation, anesthesia mode, time of returning to ward, vital signs and consciousness of patients after returning to ward, wound drainage and matters needing attention. When understanding the condition and treating the patient, we should ask the patient's real wishes and requirements. When a patient refuses treatment, the nurse should understand the patient's thoughts and reasons and make corresponding treatment. If you can't simply record the patient's refusal to infusion and therefore give up infusion treatment, you should ask the patient why he doesn't want infusion, deal with the symptoms or report to the doctor to modify the doctor's order and record it in detail.
(4) Accurate time sequence: The contents of nursing records should be recorded separately according to the time sequence of operation completion, and should not be completed at the same time.